The Ensign Group Q4 2024 Earnings Report

The Ensign Group EPS Results

• Actual EPS: $1.36
• Consensus EPS: $1.47
• Beat/Miss: Missed by -$0.11
• One Year Ago EPS: N/A

The Ensign Group Revenue Results

• Actual Revenue: $1.13 billion
• Expected Revenue: $1.13 billion
• Beat/Miss: Beat by +$2.84 million
• YoY Revenue Growth: N/A

The Ensign Group Announcement Details

• Quarter: Q4 2024
• Date: 2/5/2025
• Time: Before Market Opens
• Conference Call Date: Wednesday, February 5, 2025
• Conference Call Time: 2:00AM ET

The Ensign Group (NASDAQ:ENSG) (NASDAQ: ENSG) is a healthcare services company that provides post-acute and senior care through a network of independently operated subsidiaries. Its businesses primarily focus on skilled nursing, rehabilitation and transitional care for patients recovering from illness, injury or surgery, as well as long-term care for seniors and individuals with complex medical needs.

The company also operates or supports assisted living, independent living, memory care, home health and hospice services in selected markets. Its facilities provide services such as nursing care, physical, occupational and speech therapy, social services, and assistance with daily living. Ensign’s operating model emphasizes local leadership and the development of healthcare services tailored to the needs of individual communities.

Founded in 1999, The Ensign Group is headquartered in San Juan Capistrano, California, and serves patients and residents through facilities and healthcare operations across multiple states in the United States. The company’s leadership has included co-founder Christopher Christensen, who has served as executive chairman, and Barry Port, who has served as chief executive officer.

The Ensign Group Q4 2024 Earnings Call Transcript

Key Takeaways

• Ensign delivered record clinical and financial results in Q4 and FY 2024, with same-store occupancy up 2.7%, skilled days up 3.8%, and managed care census up 6.8%, even while adding 57 new operations.
• The company issued 2025 guidance of $6.16–$6.34 diluted EPS and $4.83 B–$4.91 B in revenue, reflecting a 13.8% earnings growth target over 2024.
• Growth accelerated through 12 new operations added this quarter across five states, bringing total footprint to 15 states and signaling significant capacity to expand into 35 additional markets.
• Balance sheet strength was highlighted by a record-low lease-adjusted net debt/EBITDA of 1.9x, over $1 B in liquidity, and a 22nd consecutive dividend increase to $0.0625 per share.
• Management expects no material near-term risk from Medicaid reimbursement changes, emphasizing ongoing advocacy efforts and preparedness for potential policy shifts.

Presentation

[Operator]

Thank you for standing by. My name is Bella, and I will be your conference operator today. At this time, I would like to welcome everyone to The Ensign Group Q4 earnings call. All lines have been placed on mute to prevent any background noise. After the speaker's remark, there will be a question-and-answer session. If you would like to ask a question during this time, simply press star, then the number one on your telephone keypad. To withdraw your question, press star one again. I would now like to turn the conference over to Mr. Keetch. You may begin.

[Chad Keetch, CIO and EVP at The Ensign Group]

Thank you, Operator, and welcome, everyone. We filed our earnings press release yesterday, and it is available on the investor relations section of our website at EnsignGroup.net. A replay of this call will also be available on our website until 5:00 P.M. Pacific on Friday, February 28th, 2025. We want to remind anyone that might be listening to a replay of this call that all statements are made as of today, February 6th, 2025, and these statements have not been nor will be updated subsequent to today's call.

[Chad Keetch, CIO and EVP at The Ensign Group]

Also, any forward-looking statements made today are based on management's current expectations, assumptions, and beliefs about our business and the environment in which we operate. These statements are subject to risks and uncertainties that could cause our actual results to materially differ from those expressed or implied on today's call.

[Chad Keetch, CIO and EVP at The Ensign Group]

Listeners should not place undue reliance on forward-looking statements and are encouraged to review our SEC filings for a complete discussion of factors that could impact our results. Except as required by federal securities laws, Ensign and its independent subsidiaries do not undertake to publicly update or revise any forward-looking statements where changes arise as a result of new information, future events, changing circumstances, or for any other reason.

[Chad Keetch, CIO and EVP at The Ensign Group]

In addition, The Ensign Group, Inc. is a holding company with no direct operating assets, employees, or revenues. Certain of our independent subsidiaries, collectively referred to as the Service Center, provide accounting, payroll, human resources, information technology, legal, risk management, and other services to the other independent subsidiaries through contractual relationships.

[Chad Keetch, CIO and EVP at The Ensign Group]

In addition, our captive insurance subsidiary, which we refer to as the Insurance Captive, provides certain claims-made coverage to our operating companies for general and professional liability as well as for workers' compensation insurance liabilities. Ensign also owns Standard Bearer Healthcare REIT, Inc., which is a captive real estate investment trust that invests in healthcare properties and enters into lease agreements with certain independent subsidiaries of Ensign as well as third-party tenants that are unaffiliated with the Ensign Group.

[Chad Keetch, CIO and EVP at The Ensign Group]

The words Ensign, Company, We, Our, and Us refer to the Ensign Group Inc. and its consolidated subsidiaries. All of our independent subsidiaries, the Service Center, Standard Bearer Healthcare REIT, and the Insurance Captive, are operated by separate independent companies that have their own management, employees, and assets. References herein to the consolidated company and its assets and activities, as well as the use of the words We, Us, and Our, and similar terms, are not meant to imply nor should be construed as meaning that the Ensign Group has direct operating assets, employees, or revenue, or that any of the subsidiaries are operated by the Ensign Group.

[Chad Keetch, CIO and EVP at The Ensign Group]

Also, we supplement our GAAP reporting with non-GAAP metrics. When viewed together with our GAAP results, we believe that these measures can provide a more complete understanding of our business, but they should not be relied upon to the exclusion of GAAP reports. A GAAP to non-GAAP reconciliation is available in yesterday's press release and is available in our Form 10-K. And with that, I'll turn the call over to Barry Port, our CEO. Barry?

[Barry Port, CEO at The Ensign Group]

Thanks, Chad, and thank you all for joining us today. Our leaders and their teams across the organization once again posted record clinical and financial results and continue to build remarkable momentum in each market across our portfolio. Our success is entirely due to the efforts and commitment of those leadership teams, caregivers, field resources, and Service Center partners.

[Barry Port, CEO at The Ensign Group]

One of our most important priorities is to support those that care for our patients every day. That core value of Customer Second is something our teams across the organizations embrace as we attract and develop caregivers and leaders. We are building a formidable bullpen of caring and passionate partners who are determined to live our mission to dignify post-acute care.

[Barry Port, CEO at The Ensign Group]

After another record year and quarter, we're excited about the many opportunities to continue to grow this effort by capturing the enormous upside in our portfolios, we relentlessly focus on fundamentals across the organization. We are pleased to see same-store and transitioning occupancy increase by 2.7% and 4.1% for the year and grow by 2.3% and 4.7% over the prior year quarter, respectively.

[Barry Port, CEO at The Ensign Group]

We also saw skilled days increase by 3.8% for our same store and 10.9% for transitioning operations over the prior year quarter. In addition, our managed care census grew by 6.6% and 27.7% for our same store and transitioning operations, respectively, over the prior year quarter. These results demonstrate the exciting momentum even in our more mature operations.

[Barry Port, CEO at The Ensign Group]

We are very pleased with these results, but even more excited about these outcomes because they were achieved while simultaneously adding 57 new operations across almost every market we serve. When we look at the combination of organic growth and new acquisitions, we see a very bright future ahead. We are very humbled by what we were able to accomplish in 2024, and we're eager to continue to drive organic improvements and take advantage of the acquisition opportunities that we see on the horizon.

[Barry Port, CEO at The Ensign Group]

We're issuing our 2025 earnings guidance of $6.16-$6.34 per diluted share and annual revenue guidance of $4.83 billion-$4.91 billion. The midpoint of this 2025 earnings guidance represents an increase of 13.8% over our 2024 results and is 31% higher than our 2023 results.

[Barry Port, CEO at The Ensign Group]

We look forward to 2025 with confidence that our partners will continue to manage and innovate while balancing the addition of newly acquired operations. This annual guidance comes on top of the extraordinary growth we experienced in the last few years.

[Barry Port, CEO at The Ensign Group]

To put this performance in perspective, over the last five years, our total revenue increased by $2.2 billion, or 109.2%, representing a 15.9% compound annual growth rate, while our diluted GAAP earnings per share grew by $3.48 in 2019 to $5.12 in 2024, representing a 25.6% compounded annual growth rate. In addition, since we spun out the Pennant Group in 2019, we have seen adjusted EPS grow by 209% with a CAGR of 25.3%.

[Barry Port, CEO at The Ensign Group]

This performance is not due to some large event or single transformative transaction, but instead is the result of steady and consistent growth and performance quarter after quarter, which comes from a collective belief and commitment held by all of our partners to expand our mission in a methodical and thoughtful way.

[Barry Port, CEO at The Ensign Group]

We look forward to the upcoming year and are confident that our partners can reach new heights in clinical and financial performance as they apply our proven locally driven model, and as we evaluate our expanding portfolio, we are very excited about the continued growth in occupancy and skilled mix that we experienced last year, which is continuing so far into the first quarter of this year.

[Barry Port, CEO at The Ensign Group]

There are so many opportunities in front of us to optimize operational efficiencies and drive occupancy and skilled mix as we continue to successfully unlock value and opportunity in the dozens of recently acquired operations. Our leaders are poised to again showcase our ability to find, acquire, and transition performing and underperforming operations by applying proven Ensign principles developed over 25 years. Next, I'll ask Chad to add some additional insights regarding our growth. Chad?

[Chad Keetch, CIO and EVP at The Ensign Group]

Thank you, Barry. As we expected, we continue to add to our growing portfolio and are thrilled with the 12 new operations we added during the quarter and since. These include the following: one in Alabama, eight in Tennessee, one in Wisconsin, one in Texas, and one in Nebraska. In total, we added 1,147 new skilled nursing beds and 16 senior living units across five states. Of these new operations, six of them included the real estate assets, which were acquired by Standard Bearer and leased to an Ensign-affiliated operator.

[Chad Keetch, CIO and EVP at The Ensign Group]

This growth brings a number of operations acquired in 2023 and since to 64, 38 of which were acquired since January 2024. We are excited to add density in one of our newest markets in Tennessee and look forward to deepening our relationships in the healthcare community and building upon the foundation of our strong local leadership.

[Chad Keetch, CIO and EVP at The Ensign Group]

We are also eager to see our first operation in Alabama gain strength and look forward to bolstering our presence in that state over time. As we have talked about before, entering new states is a significant undertaking that, for us, must be driven by a proven Ensign leader who is committed to and has a connection with the new geography.

[Chad Keetch, CIO and EVP at The Ensign Group]

As most of you know, the foundational principle of our entire strategy is the recognition that post-acute care is a locally driven business, and the success or failure of any operation is largely determined by the quality of the leadership and the vision of the team leading each unique multi-million dollar business. In addition, having the support of local resources and experts from nearby states has also proven to be a successful model when opening a new market.

[Chad Keetch, CIO and EVP at The Ensign Group]

Lastly, when we go into a new state, we typically look to start with one or two buildings so we can establish a solid launching point for more growth. With Alabama, we were able to check all those boxes and have an outstanding Ensign leader who has relocated to direct our efforts there in our first building, with the support of our talent in Tennessee and South Carolina.

[Chad Keetch, CIO and EVP at The Ensign Group]

Over time, as we gain strength in our first operation, we will look to add additional facilities to establish our first Alabama cluster. As we have seen recently with Tennessee, eventually this will grow into multiple clusters, which will eventually comprise a sizable market. We can't wait to watch Alabama become another reflection of the template of growth and development we've seen across our footprint over the last 25 years.

[Chad Keetch, CIO and EVP at The Ensign Group]

We remind you that we are now only in 15 states and have significant bandwidth to grow in the other 35 states. Looking forward, we have already announced a new transaction, which we expect to close in the next few months. That includes two new states, Alaska and Oregon. As with Alabama, each of these new states is driven by an Ensign leader and will represent a small investment with plans to build over time.

[Chad Keetch, CIO and EVP at The Ensign Group]

With all that being said, during 2024 and since, we added new operations in all but two of our existing 15 states, spreading out the growth across many markets. While we will continue to evaluate new states that fit our criteria, we will prioritize growth in our established geographies.

[Chad Keetch, CIO and EVP at The Ensign Group]

This not only allows us to deepen our commitment to these markets, but because our transitions do not rely on a centralized acquisition team, our growth is not limited by typical corporate bottlenecks. Instead, we look to our local cluster partners to implement the transition plans. So while our rate of growth this year was strong, the distribution of our growth across many markets leaves us with significant bandwidth to grow in most of our markets.

[Chad Keetch, CIO and EVP at The Ensign Group]

We still see significant opportunity to continue to add meaningful density in the markets we know best and are making progress on several additions that we expect to close in the next few months. While we expect the current rate of acquisitions to continue this year, we remain committed to staying true to the proven deal criteria that have allowed us to grow in a healthy and sustainable way.

[Chad Keetch, CIO and EVP at The Ensign Group]

We continue to see more and more opportunities to acquire new operations, and our focus is to carefully choose the acquisitions that will be accretive to shareholders. Our local leaders continue to recruit future CEOs for Ensign-affiliated operations, and we have a deep bench of CEOs in training that are eagerly preparing for their opportunity to lead.

[Chad Keetch, CIO and EVP at The Ensign Group]

We still see evidence that many operators in this industry are struggling, and we expect that the operating environment will translate into many near and long-term opportunities to both lease and acquire post-acute care assets. However, we do not set arbitrary growth goals and will remain true to our disciplined acquisition strategy. We only grow when we have the right leaders in place and the pricing is right.

[Chad Keetch, CIO and EVP at The Ensign Group]

The scalability of our growth model, our healthy balance sheet, combined with the numerous opportunities we see in our existing footprint, give us enormous potential to continue to apply our proven acquisition and transition strategies in 2025. We are also providing additional disclosure on Standard Bearer, which added 13 new assets during the quarter and since and is now comprised of 129 owned properties.

[Chad Keetch, CIO and EVP at The Ensign Group]

Of these assets, 97 are leased to an Ensign-affiliated operator and 33 are leased to third-party operators. 10 of these 13 new real estate assets are operated by an Ensign-affiliated operator, and three of these properties are senior living assets that are operated by a high-quality third-party tenant under triple-net long-term lease.

[Chad Keetch, CIO and EVP at The Ensign Group]

Going forward, Standard Bearer continues to work together with its operating partners at Ensign to acquire portfolios comprised of operations that Ensign would operate and facilities that third parties that are interested in operating under a lease. In addition, over the coming months, Standard Bearer also anticipates announcing more acquisitions of real estate that will be operated by third-party operators.

[Chad Keetch, CIO and EVP at The Ensign Group]

Collectively, Standard Bearer generated rental revenue of $25.1 million for the quarter, of which $20.7 million was derived from Ensign-affiliated operations. For the quarter, Ensign reported $15.3 million in FFO and, as of the end of the quarter, had an EBITDA to rent coverage ratio of 2.5x. And with that, I'll turn the call over to Spencer, our COO, to add more color around operations. Spencer?

[Spencer Burton, President and COO at The Ensign Group]

Thank you, Chad, and hello, everyone. The incredible results that we experienced this past quarter and year were fueled by a combination of innovation and solid growth fundamentals in our more mature operations, along with exciting improvements being made in our newer acquisitions. The first example comes from our same store category. Victoria Healthcare and Rehabilitation, a 79-bed skilled nursing facility located in Costa Mesa, California, became an Ensign affiliate back in 2003, and it has been a consistent performer every year for the past two decades. The facility's consistency is driven in part by committed, stable leadership.

[Spencer Burton, President and COO at The Ensign Group]

CEO Michael Uhas has led the facility since completing his AIT program in 2015. And Joyce Tamayo, the COO, has been part of Victoria since joining as a frontline RN 18 years ago. Since then, she has systematically worked through most clinical leadership roles at the facility, including Director of Nursing.

[Spencer Burton, President and COO at The Ensign Group]

However, despite a legacy of excellence, 2024 was undeniably a breakout year for Victoria. The Victoria team grew overall occupancy from an already strong 93% in Q4 of 2023 to 95.9% in Q4 of 2024, and skilled revenue mix increased to an astonishing 75.2% during that same period, an improvement of 420 basis points. This performance was fueled by strong growth both in Medicare and managed care days. Costa Mesa is a highly complex and competitive environment with deep saturation of managed care and hospital-based health plans.

[Spencer Burton, President and COO at The Ensign Group]

So Victoria's census growth was only made possible by its consistent achievement of outstanding clinical outcomes. Victoria is currently rated five-star by CMS for health inspections, quality measures, and overall. Even more impressive, despite operating in a very rigorous state regulatory region, Victoria's state survey scores are 14 times better than the California average.

[Spencer Burton, President and COO at The Ensign Group]

As you would expect, these clinical and occupancy results have led to growth in the business. Revenues increased 14% in Q4 over prior year quarter, and EBIT skyrocketed during that same period. Victoria is a prime example of the ongoing potential in legacy operations that can be tapped as strong, experienced teams build clinical excellence. Our second example comes from our transitioning facilities group.

[Spencer Burton, President and COO at The Ensign Group]

Boulder Canyon Health and Rehabilitation in Boulder, Colorado, is a 140-bed SNF that was acquired in 2021. It demonstrates how a turnaround occurs as local leaders apply proven Ensign principles to their unique and often difficult circumstances. Like many of our acquisitions, as of the transition date, Boulder Canyon was a one-star facility with occupancy below 60%. The facility was losing money and was deeply dependent on nursing agency just to meet basic patient needs.

[Spencer Burton, President and COO at The Ensign Group]

Despite these challenges, CEO Ray Lauritzen, COO Jerelyn Lindsey, and their team went to work. They methodically established a culture of love and high achievement and actively recruited the top clinical talent in their area. They built an impressive leadership team and focused on elevating the experience of their frontline employees. As a result, in 2024, the facility completely eliminated nursing agency use despite growing their workforce to care for increased acuity and occupancy.

[Spencer Burton, President and COO at The Ensign Group]

While quality transformations were happening inside the facility, the Colorado Resource Team worked alongside facility leaders and cluster partners to transform Boulder Canyon's external reputation, including winning over local hospital systems and key managed care organizations. Recently, one of Colorado's largest narrow network plans added Boulder Canyon as a preferred provider, based on the changes in the facility's quality metrics and the trust that they had built working with a sister facility over the years.

[Spencer Burton, President and COO at The Ensign Group]

Today, Boulder Canyon enjoys a newly remodeled physical plant, great quality metrics, and an overall five-star rating from CMS. Total occupancy for Q4 of 2024 averaged 84.4%, with skilled Medicare days increasing by 70% and managed care days growing by over 200% compared to Q4 of 2023.

[Spencer Burton, President and COO at The Ensign Group]

This stability in labor and growth in census has resulted in a 23% increase in net revenue and a 131% growth in EBIT over the prior year quarter. And if you ask the team at Boulder Canyon, they are just scratching the facility's potential. With that, I'll turn the time over to Suzanne to provide more detail on the company's financial performance and our guidance, and then we'll open up for questions. Suzanne?

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Thank you, Spencer, and good morning, everyone. Detailed financials for the year and the quarter are contained in our 10-K and press release filed yesterday. Some additional highlights include the following for the year: GAAP diluted earnings per share was $5.12, an increase of 40.3%. Adjusted diluted earnings per share was $5.50, an increase of 15.3%. Consolidated GAAP revenues and adjusted revenues were both $4.3 billion, an increase of 14.2%. GAAP net income was $298 million, an increase of 42.3%.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Adjusted net income was $320.5 million, an increase of 17.2%. For the quarter, GAAP diluted earnings per share was $1.36, an increase of 257.9%. Adjusted diluted earnings per share was $1.49, an increase of 16.4%. Consolidated GAAP revenue and adjusted revenues were both $1.1 billion, an increase of 15.5%. GAAP net income was $79.7 million, an increase of 267.4%. Adjusted net income was $87.6 million, an increase of 18.9%.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Other key metrics as of December 31st, 2024, include cash and cash equivalents of $464.6 million and cash flow from operations of $347.2 million. During the quarter, the company increased its dividend for the 22nd consecutive year and paid a quarterly cash dividend of $0.0625 per common share. We have a long history of paying dividends, and as the company's liquidity remains strong, we plan to continue its long history of paying dividends into the future.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

We also continue to delever our portfolio, achieving a record-low lease-adjusted net debt-to-EBITDA ratio of 1.9 times. Our ability to delever even during periods of significant growth is particularly noteworthy and demonstrates our commitment to disciplined growth, as well as our belief that we can continue to achieve sustainable growth in the long run.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

In addition, we currently have $572 million of available capacity on our line of credit, which, when combined with our cash on our balance sheet, gives us over $1 billion in dry powder for future investments. We also own 134 assets, of which 129 are held by Standard Bearer and 110 are owned completely debt-free and are gaining significant value over time, even adding more liquidity to help with future growth.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

As Barry mentioned, we are providing our annual 2025 earnings guidance between $6.16 and $6.34 per diluted share, our annual revenue guidance between $4.83 billion and $4.91 billion. We have evaluated multiple scenarios and, based on the strength of our performance and the positive momentum we've seen in occupancy and skilled mix, as well as the continued progress on agency management and other operational initiatives, are confident that we can achieve these results.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Our 2025 guidance is based on diluted weighted average common shares outstanding of 59.5 million, a tax rate of 25%, the inclusion of acquisitions closed and expected to close through the second quarter of 2025, the inclusion of management expectations for Medicare and Medicaid reimbursement rate net of provider tax, with the primary exclusion coming from stock-based compensation.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Additionally, other factors that could impact quarterly performance include variations in reimbursement systems, delays and changes in state budgets, seasonality in occupancy and skilled mix, the influence of the general economy on census and staffing, the short-term impact of our acquisition activities, variations in insurance accruals, and other factors. And with that, I'll turn it back over to Barry. Barry?

[Barry Port, CEO at The Ensign Group]

Thanks, Suzanne. As we wrap up, I must reemphasize, as I always do, how incredibly honored and grateful that we all are to work alongside our operational leaders, field resources, clinical partners, and Service Center team that are behind these record-setting results. We are completely amazed by their impressive resiliency as they focus on elevating and loving everyone around them. Their collective commitment is truly a blessing. Our future is bright, and we're excited for a busy year ahead. And with that, we'll now turn it over to the Q&A portion of our call. Bella, can you please instruct the audience on the Q&A procedure?

[Operator]

At this time, I would like to remind everyone, in order to ask a question, press star, then the number one on your telephone keypad. We will pause for just a moment to compile the Q&A roster. Your first question comes from the line of Ben Hendrix from RBC Capital Markets. Your line is now open. Please go ahead.

[Ben Hendrix, Equity Research Analyst at RBC Capital Markets]

Thank you very much, guys, and congratulations on the results. I just wanted to get your latest thoughts on the Medicaid reimbursement backdrop. Clearly, you guys have had great luck bridging from the COVID-era FMAP payments through the end of the public health emergency. But looking forward, are there any specific programs or aspects of programs, supplemental quality incentive or otherwise, that you're exposed to that might be at particularly high risk for cost savings cuts under the new administration versus others? Thanks.

[Barry Port, CEO at The Ensign Group]

Look, you know it's hard to know exactly where things are going to go during the kind of reconciliation process and what will actually become a priority in terms of legislation. I can tell you that we are prepared through our industry association and our lobbyists there to help educate members of Congress on any one of the scenarios that might be further explored.

[Barry Port, CEO at The Ensign Group]

Our association has been really nimble and good at having language and legislative options prepared and really just a robust kind of education effort around impacts to the Medicaid program as it relates to seniors. But for us, it's not clear as to what will become a priority. All we can really do is just make sure that we're part of the education process.

[Barry Port, CEO at The Ensign Group]

In the meanwhile, we can also just kind of reiterate what we know about the Trump administration, that they're committed to the Medicaid program. He said that publicly. He said it as recently as Friday, and he's committed to the senior industry as well, senior care industry, so we prepare for the worst, as always, but I think having Medicaid be impacted in a broad-based way is going to be a pretty difficult task for Congress during the reconciliation process, but as for now, no, none of our programs are really at risk that we are aware of.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Yeah, and I would just add, typically in a Republican control, you definitely usually see lighter regulations while there might be some things on the rate, and so, as you stated in the question, we really try to be nimble during these times and really utilize that, so if there's regulatory relief, there is some flexibility in our operating model with that, and then our involvement at the state level is very deep from the legislative side, as well as just all the associations that we have at each individual state.

[Ben Hendrix, Equity Research Analyst at RBC Capital Markets]

Thanks a lot. And if I could just follow up real quick, specifically on Tennessee, just given your M&A acquisition there, I just wanted to get your thoughts on kind of the overall backdrop, both from a Medicaid perspective, but also just what you're seeing on the horizon in terms of opportunities for preferred provider relationships, kind of like what you called out for Boulder Canyon. Thank you.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Yeah. So just taking a step back and looking at the overall Tennessee market that we're new to, obviously they have, and I think there's a lot of noise in the press just because of all the hospitals and the larger reimbursement amounts that they receive in Tennessee. Obviously, the amount of supplemental associated with our operations is substantially less than that.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

And really, it is carried all the way through and approved all the way through July 1st of this year. And then they're looking to and working with the legislation there in Tennessee to actually continue that on through the later portion of the year as it relates to skilled nursing. But again, it's not the amounts that you're seeing with other large hospitals. With regards to networking, obviously, we've been in that state. I think we talked about this.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Anytime we enter a new state, we are doing a lot of preparation. The operator who kind of had founded that state has been there for a very long time and has established great relationships over this period of time, not only that individual, but others that we have left on from the acquisition and others that we actually had as resources in that state have great connections out there.

[Ben Hendrix, Equity Research Analyst at RBC Capital Markets]

Great. Thank you.

[Operator]

Our next question comes from the line of Scott Fidel from Stephens. Please go ahead.

[Raj Kumar, Analyst at Stephens]

Hi. This is Raj on, for Scott. I had a couple of modeling questions. This first around quarterly EPS seasonality in relation to maybe 2024, even historically, and what's kind of baked-in guidance from an occupancy and skilled mix perspective.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Yeah. Kind of going 2024 seasonality first, obviously. Q4 historically on the occupancy and skilled mix, and Q1 have been the best quarters that we've had, typically higher skilled mix, higher occupancy in both of those quarters. When we look at this year's Q4, obviously, we saw something flat to Q3. The reason why it was flat was because Q3 was so great.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

And I think you saw during our earnings call, kind of subsequent conversations after that, we had that heightened Q4 occupancy, really retained that market share. When we looked at hospital occupancy, we were able to keep all the market share and just really had a great Q3, which then continued into Q4 and is continuing into Q1. Like I mentioned, Q1 historically has been our strongest occupancy and skilled mix seasonality, and we see that same seasonality continuing in 2025.

[Raj Kumar, Analyst at Stephens]

Thank you. And then, just as a follow-up, just around cash flow from operations, kind of expectations there, and anything you'd like to call out that'd be unique to 2025 other than the typical working capital seasonality.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

Yeah. I think one of the things that we need to keep in mind, and this is just every time we have very heavy acquisitions, specifically right now, we're seeing as we go through that licensing process and that change of ownership process, there have been substantial delays. We've seen slowdowns at the Medicaid offices and approval offices for licensing.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

And so kind of that cycle that we're typically seeing will probably draw out as we continue this acquisition pathway. And so we actually see a little bit stretching on that cash flow and the cash turnaround as those acquisitions continue to come in and the slowdown from the Medicaid offices and other offices out there.

[Chad Keetch, CIO and EVP at The Ensign Group]

It's just a temporary phenomenon while we're waiting to get those Medicaid certifications and everything turned on, but it can impact the cash flow in the short run.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

And then other than that, obviously, Q4 saw a little bit of an unusual cash payment as we foreshadowed during the Q3 call. We did have that payment of the settlement that happened a year ago. So that was a little bit dip in the Q4 cash flow.

[Operator]

Your next question comes from the line of AJ Rice with UBS.

[AJ Rice, Managing Director at UBS]

Hi, everybody. First question, just to ask maybe a little bit about labor cost trends. What are you seeing there? I know it's been moving more favorable in the last year or so. What do you see as you move into 2025? And is there anything specific around the workforce standards program in California that you're factoring into your outlook and how that might impact you?

[Spencer Burton, President and COO at The Ensign Group]

Just maybe starting with the general labor environment. We're not seeing massive changes, but we're seeing very gradual improvement that continues quarter to quarter recently. We expect that to continue. Some of that's just environmental. The labor markets have stabilized more and more since COVID. And part of it is we're relentlessly working on new ways to attract labor, retain the best nurses, the best CNAs, the best frontline workers.

[Spencer Burton, President and COO at The Ensign Group]

And then also, we're looking for leadership development opportunities because our business is very locally driven. And if you have a great local leadership team, that's really the key to having a healthy frontline workforce. And so as we continue to do those things, we think a combination of environmentally, the markets are a little bit better. And as we get better, that bodes well for 2025.

[Suzanne Snapper, EVP and CFO at The Ensign Group]

And the California workforce standard is all baked into the guidance for 2025. We've already included that. We also have this is going to be the second year that we're going to be going through that program. And so we've got a good handle on expectations associated with that program based upon what the state has published.

[AJ Rice, Managing Director at UBS]

Okay, and maybe just the follow-up question beyond the deal pipeline. What are you seeing? Are the terms on the deals that you're doing changing in any way? What does the competitive landscape around acquisitions look like right now?

[Chad Keetch, CIO and EVP at The Ensign Group]

A great question. As we kind of said in the prepared remarks, we're seeing a lot of deal flow. And we actually, we've acquired a lot just in the last 18 months, and we expect to continue kind of on the same pace in 2025. So we've got a lot of deals lined up that we'll be closing over the next several months.

[Chad Keetch, CIO and EVP at The Ensign Group]

As Suzanne mentioned earlier, we are seeing some delays in the change of ownership from the state and granting licenses and stuff like that are really like the deals are locked up. We're just waiting to get those licenses. So you'll see us start announcing more closings over the next few months. In terms of competitive landscape, there are way more deals on our desk than we could ever dream of doing. So we are able to be very, very selective.

[Chad Keetch, CIO and EVP at The Ensign Group]

We often talk about this disciplined growth. That's a lot of things, making sure we have leaders in the markets, leaders that are ready to go to assume the responsibility to transition these buildings. That's obviously the first thing, but also the terms of the acquisitions.

[Chad Keetch, CIO and EVP at The Ensign Group]

We're really particular about making sure if it's a lease that there's plenty of coverage and we're not stretching and looking at pro forma results and establishing the rents. We're pretty firm on using the trailing 12 and not paying for performance that we're going to create. When we're buying the real estate, we're really focused on price per bed and making sure it's in line with kind of what we see as sustainable prices that will allow us to have the balance sheet that we do.

[Chad Keetch, CIO and EVP at The Ensign Group]

And you can't grow as quickly as we have over time and have a healthy balance sheet if you overpay on things. So that's all kind of how we look at it. But so with all that said, there's many opportunities for us as we're going through that discipline analysis on deals. We tend to win the deals that we want and that we're ready to move forward with and expect that to continue.

[AJ Rice, Managing Director at UBS]

Okay. Great. Thanks.

[Operator]

Again, if you would like to ask a question, press star one on your telephone keypad. That concludes our Q&A session. Ladies and gentlemen, thank you all for joining. You may now disconnect.

Participants

Executives

• Barry Port, CEO
• Spencer Burton, President and COO
• Chad Keetch, CIO and EVP
• Suzanne Snapper, EVP and CFO

Analysts

• AJ Rice, Managing Director at UBS
• Raj Kumar, Analyst at Stephens
• Ben Hendrix, Equity Research Analyst at RBC Capital Markets